Depressive symptoms among individuals identifying as asexual: a cross-sectional study

Although asexuality became a growing research subject over the last decade, data on the mental health of individuals identifying as asexual is still rare. The key objective of the present study was to examine depressive symptoms among individuals identifying as asexual. Data of LGBTQIA+ (Lesbian, Gay, Bi-sexual, Trans*, Queer, Inter*, Asexual and/or + indicating others within the community) and cisgender heterosexual individuals was collected through an online survey during the COVID-19 lockdowns in Germany. The survey included questions about sexual and gender identity, depressive symptoms, and asexual identity. An analysis of N = 6601 participants was conducted. A total of n = 445 individuals identified as asexual. Regression results indicated identifying as asexual being significantly associated with higher depressive symptoms. Results suggest that individuals identifying as asexual represent a vulnerable group within the group of sexual minorities, one that fundamentally requires special psychosocial support, especially in times of pandemics.

expression of love." 4 .Therefore, the term asexuality includes a variety of non-sexual attractions and at the same time does not exclude people on this spectrum from performing sexual intercourse.
When conceptualizing the term, it is important to consider that the spectrum of asexuality has been erased and denigrated in our society 5 .Hammack, Frost and Hughes emphasize the normative assumptions about intimacy "that privilege heterosexual monogamy and the biological family unit, presume binary cisgender identities, essentialize binary sexual identities, and view sexual or romantic desire as necessary." 6 .Instead they propose a queer paradigm to study relationship diversity.When defining asexual identity, allonormativity and heteronormativity must be taken into account.
While asexuality became a growing subject during the last decade (health) data on individuals identifying as asexual remains rare.The definition and measures of asexuality vary widely across research leading to a wide range of estimates of prevalence across studies 7 .For example, in a UK sample a study reported estimates of people identifying as asexual ranging from 0.6 to 5.5% 8 .Results from large-scale national probability studies of British residents reported estimates between approximately 0.4-1% [8][9][10] .A study from Finland reported that 3.3% of women never felt sexually attracted to anyone 11 : Overall, there is a higher proportion of women who identify as asexual, compared to men 3,12 .Furthermore, asexual individuals are found to be less likely in a romantic relationship 3,10,12 .In this context the term allosexual was established by the asexual community to describe everyone who experiences sexual desire towards others-anyone who is not asexual 1 .Moreover, studies including asexual individuals often exclude those individuals from the main analysis 13 or categorize individuals identifying as asexual into "other groups" 14,15 .This study aims to address this gap by examining a substantial sample size of asexual individuals as part of the main research question.
In addition to demographics, recent research has been focusing on the link between asexuality, well-being and (mental) health.There is evidence indicating specifically higher rates of depressive symptoms, anxiety, suicidality and psychoticism among asexual men, compared to heterosexual men 16 .Further, a recent study found that 64.8% of individuals identifying as asexual reported experiencing minority stress based on sexual and/or romantic orientation 17 .In the same study, about 32% of those individuals reported suicidal ideation, about 11% had suicide plans, and about 3% attempted suicide in the past 12 months.Previous empirical evidence indicates an association between asexuality and higher rates of mood and anxiety disorders 16,18 .
Conceptual frameworks, such as the Minority Stress Model, explain the link between discrimination, social stress, and mental health among LGBTQIA+ communities (Lesbian, Gay, Bi-sexual, Trans*, Queer, Inter*, Asexual and/or others within the community) 19,20 .The model postulates that belonging to sexual minority groups entails a stress exposure, which negatively affects well-being 21 .These stressors include stigmatization, discrimination or exposure to violence.Overall, recent studies conducted during the COVID-19 pandemic reported poorer mental health among individuals from minoritized sexual identities 15,22 .However, asexual and bisexual individuals are particularly vulnerable to poorer well-being 22,23 .A multivariate meta-analysis found that asexual and bisexual individuals were found at greater risk of higher levels of depressive symptoms compared to gay/ lesbian and heterosexual individuals 24 .Asexual individuals reported higher internalized LGBTQIA+ -phobia and poorer mental health compared to allosexual individuals 25 .
However, the link between asexuality and mental health remain inconsistent, as other studies have not found a link between asexuality and poorer mental health 12,26 .For example, Rothblum et al. found no differences between asexual individuals and allosexual individuals regarding general well-being, life satisfaction, and social support 27 .Nevertheless, until now, there has been a notable absence of in-depth analysis concerning the mental health of asexual individuals.Further research is needed to gain a better understanding of the association between the spectrum of asexuality and mental health.Moreover, many studies investigating the mental health of asexual individuals have limited their analysis to binary gender options (male and female), neglecting other gender identities 16,26,[28][29][30] .This highlights a significant gap in the specific analysis of the mental health of asexual individuals.

Aims of the study
The study aims to address the paucity of research about asexual individuals by focusing on this population and examining their mental health, specifically depressive symptoms, in comparison to allosexual individuals.The study has two primary objectives: 1. To provide descriptive data on asexual individuals in Germany, which is currently lacking in the literature.
While the study does not aim to assess changes in depressive symptoms before and during the COVID-19 pandemic through a before-and-after comparison, it acknowledges the pandemic as a significant influence on the study environment.2. To investigate potential differences in depressive symptoms between asexual and allosexual individuals.
Based on prior research indicating higher levels of mental health problems among asexual individuals, we hypothesize that those identifying as asexual will exhibit greater depressive symptoms compared to allosexual individuals.
We will first conduct comparisons of age, sexual orientation, and gender identity between asexual and allosexual individuals.This will provide a foundation for understanding the demographic characteristics of the asexual population in our study.Subsequently, we will examine the differences in depressive symptoms between the two groups, with the expectation that asexual individuals will report higher levels of depressive symptoms compared to their allosexual counterparts.

Participants and procedure
Cross-sectional data was collected using an online survey during the first (March/April 2020) and the second (January/February 2021) COVID-19 lockdowns in Germany, with data acquisition being open each time for two respectively 3 weeks.To oversample LGBTQIA+, LGBTQIA+ groups and organizations in Germany were contacted and asked to distribute the survey and share the survey on their social media.Calls for participation were announced on social media feeds that specifically engage with the LGBTQIA+ population.
The study was conducted in accordance with the Declaration of Helsinki.Data collection was anonymous, and all participants gave informed consent prior to participation.As data acquisition was anonymous and without identifying variables, no ethical approval was necessary from the ethics committee of the Charité -Universitätsmedizin Berlin.Participants did not receive any kind of incentive or remuneration.

Sexual orientation
Sexual orientation was assessed through a multiple answer questions featuring the orientations: "aromantic", "asexual", "bisexual", "gay [German slang for "schwul"]", "heterosexual", "homosexual", "lesbian", "queer", "pansexual" and "alternative".Every orientation could be chosen and multiple answers were possible.The categories aromantic and queer were only added in the second wave of the survey.For further analysis, the dichotomous variable asexual identification (yes = asexual identity, no = allosexual identity) was coded.Further, sexual identity was created as a dichotomous variable: heterosexual versus queer (bisexual and/or gay and/or homosexual and/ or lesbian and/or queer and/or pansexual).

Gender identity
Gender identity was assessed with the same multiple answer sheet offering the identities: "cis", "inter", "man", "non-binary", queer", "trans", "woman", and "alternative".Each category could be chosen and multiple answers were possible.For further analysis, the dichotomous variable gender identity: TIN (trans* and/or inter and/or non-binary and/or queer) yes or no.

Depressive symptoms
Depressive symptoms were measured with the 8-item questionnaire "Depressive symptoms in a non-clinical context" 31 .The items measure impairments of well-being on a 7-point Likert scale with 1 indicating no agreement and 7 indicating strong agreement.The scale was calculated as a mean of the 8-items, with higher scores indicating higher levels of depressive symptoms.Reliability was high with Cronbach's alpha of 0.90.

Analysis
First, descriptive analyses (i.e., frequencies for categorical variables) for all participants across both cohorts were calculated.Next, a standardized comparison of means was performed with a chi-square for categorical variables.Third, to test the main research question, a multiple regression with depressive symptoms as a dependent variable was performed.Age categories (18-25 years old, 26-35 years old, 36-45 years old, and 46 years or older), gender identity (TIN yes or no), and sexual orientation (heterosexual yes or no) as well as asexual identity (yes or no) were included in the model.Only participants were included in the analysis that provided information on asexual identity.Missing data was excluded in the analysis.For the regression, adjusted R2, F values (F), degrees of freedom and significance levels (p) are reported.All tests of significance were based on a p < 0.05 level and confidence interval (CI) of 95%.All statistical analyses were performed using IBM SPSS Statistics for Windows V.27.0.

Statement of ethics
All participants gave their informed consent before taking part in the online survey.Data acquisition was anonymous without identifying variables.Because of the anonymity of the study, the consultation of an ethical review board was not necessary.Participants did not receive any kind of incentive or remuneration.

Participants
A total of N = 6870 people participated in the survey.Data of N = 6601 participants were included in the analysis.A total of n = 445 (6.7%) participants of the sample reported an asexual identity.Distributions and comparisons of age, sexual orientation, and gender identity for all individuals and between individuals identifying as asexual or allosexual can be obtained from Table 1.Overall, about 42% (n = 186) of individuals identifying as asexual were in the age group 18-25 years old and 44% of individuals identifying as asexual (n = 196) identified as female.One third (33.8%) of individuals identifying as asexual identified as queer, lesbian, or gay.Individuals identifying as asexual were more likely to report a TIN gender identity compared to allosexual individuals (58.8% versus 18.2%).

Conclusion
The key objectives of this study were to examine spectrum of asexuality and to study depressive symptoms among individuals identifying as asexual compared to allosexual individuals in Germany.The data were collected during the initial phases of the COVID-19 pandemic lockdowns.Our findings indicate differences between age, sexual orientation and gender identity between asexual individuals and allosexual individuals.Individuals identifying as asexual reported higher levels of depressive symptoms.A total of 445 individuals identifying as asexual took part in the survey, comprising 6.5% of the sample.This proportion exceeds the prevalence rate between 1 and 5. 5% reported in previous studies 8,32 .It is essential to note that the overrepresentation of LGBTQIA+ community members in our study and the self-identification of asexuality without further elaboration may have contributed to the higher frequencies observed.Consistent with prior research, the data collected in this study demonstrates substantial associations between individuals identifying as asexual and non-binary and trans* identities 12,27,33,34 .Furthermore, a notable predominance of female gender identity among individuals identifying as asexual, consistent with previous research was evident 35 .
Looking at depressive symptoms, individuals identifying as asexual reported higher depressive symptoms in comparison to the allosexual group during the pandemic.Similar to previous work studying a potential vulnerability of sexual and gender minorities with regard to (mental) health individuals identifying as asexual reported higher levels of depressive symptoms 14,15,36 .This is independent of their sexual orientation and gender identity.The present finding is also in line with past research examining mental health among individuals identifying as asexual 22,23 .The increased harmful stereotypes about asexuality, also from within the LGBTQIA+ Community, reported in previous studies may increase the mental health difficulties in individuals identifying as asexual and be a reason for this effect 16,37 .Future research is needed in order to better understand the mechanisms behind the notable vulnerability of individuals identifying as asexual for greater mental health burden.

Strengths and limitations
A particular strength of this study was the high number of participants.Further, we included a vast range of sexual and gender identities, to foster inclusivity in examining mental health among LGBTQIA + individuals.Due to the various selection possibilities, a more detailed analysis was possible in comparison to studies that for example assess gender in a binary format 26,28 .The multiplicity of gender identities recorded and the large sample size have produced new insights about asexuality.
Nevertheless, a few important limitations must be outlined.The main limitation of the present study is its cross-sectional design.The study was recruited during the COVID-19 pandemic without longitudinal data before or after the pandemic.Therefore, we cannot conclude whether the pandemic or other relevant factors related to this issue might have influenced our results.Another limitation is the lack of data on education and income.Intersectional approaches when studying mental health at the intersection of gender identity, sexual identity, income/class and race/ethnicity are of great importance.These factors intersect to jointly impact mental health in complex ways, and where not considered in the present analysis.For example, a recent study reported higher major depression and generalized anxiety rates among low-income students, students of color and LGBTQIA+ students, including asexual individuals 38 .Same-sex parents and single LGBTQIA+ parents also had a higher risk of poverty during the pandemic 39 .The present analysis did not record education, income, or race.Future research should include other domains of diversity such as income and ethnicity should be considered in further studies when examining mental health of sexual minorities 40 .Further, the lack of differentiating between the sexual and the romantic orientation in the present analysis represents another limitation.When studying the spectrum of asexuality, it is of great importance to differentiate between the sexual and the romantic orientation.Although past research found, that asexual individuals are less likely than allosexual individuals to be a romantic relationship 12 , individuals identifying as asexual can experience romantic attraction 3 .Asexual communities often make a distinction between sexual and romantic attraction.Romantic attractions include labels like heteroromantic, homoromantic, and biromantic.However, since the present study did not only focus on individuals identifying as asexual, it was challenging to capture romantic and sexual orientation separately, a problem that has been already reported previously 41 .However, future research should include a distinction between the sexual and romantic orientation in their survey when studying the asexual individuals.Hopefully, with increasing acceptance and visibility of the asexual community, these formulations will also become more common and discourses around desire more inclusive.Additionally, the self-identification of asexuality did not allow for placing the individuals on a spectrum but just ticking a box.Thus, e.g., demisexuality as option was missing.Finally, as already mentioned, the oversampling of the present study needs to be addressed as a limitation.The sample of the presents study is not representative for the general population in Germany.Present data was collected in Germany, a country with equality laws and policies.Past research has numerous times outlined differences in equality for LGBTQIA+ individuals across countries 42 .Thus, present results are mainly transferable to western countries 9,43 .

Conclusion
In conclusion, this study highlights the need for further research into the spectrum of asexuality, including an exploration of social support among individuals identifying as asexual.Health practitioners, as well as members of the LGBTQIA+ community, should be better informed about the asexual spectrum to support the specific needs of individuals identifying as asexual and combat harmful stereotypes.In particularly (mental) health practitioners, which in recent studies were found to be part of a stigmatizing experience, should be more informed about the spectrum of asexuality and know how to assess the specific needs of individuals identifying as asexual 44,45 .Our findings suggest that knowing the sexual orientation identity of their patients may be helpful